Thinking About Ob/Gyn

Surgical techniques in gynecology vary widely between surgeons, creating both excitement and frustration for residents trying to learn the "right way" to perform procedures. Howard and guest host Maddie White discuss this and more:• Trocar placement during laparoscopy requires careful consideration of patient factors and potential adhesions• Elevating the abdomen during trocar placement remains standard practice, though definitive evidence on its necessity would require studies of over 100,000 patients• Surgeons should understand power analysis to recognize when studies are underpowered to detect meaningful differences in rare complications• Visceral slide technique using ultrasound can identify adhesions and determine the safest entry point for laparoscopic surgery• Palmer's point may no longer be the safest entry point for many patients given the prevalence of bariatric surgeries• Jain's point (lateral to the umbilicus) may now be statistically safer for many patients with complex surgical histories• Vaginal cuff dehiscence rates are 6-10 times higher with laparoscopic/robotic hysterectomy compared to vaginal approaches• The higher dehiscence rate stems from using energy devices for colpotomy rather than cold scalpel techniques• Barbed sutures simplify cuff closure but don't reduce dehiscence rates compared to standard suturing techniques• Surgery consists of "a thousand little things done well" - mastering these micro-skills distinguishes excellent surgeons00:00:00 Surgical Techniques: Excited and Frustrated00:08:00 Elevation During Trocar Placement 00:17:00 Evidence and Power Analysis00:21:35 Visceral Slide Technique00:35:10 Alternative Trocar Entry Points00:40:10 Cuff Closure and Dehiscence Risk00:51:45 Laparoscopic vs Vaginal Colpotomies01:03:00 First Accredited OB-GYN Residency ProgramFollow us on Instagram @thinkingaboutobgyn.

Howard Herrell and Antonia Roberts explore evidence-based practices in obstetrics and gynecology, examining both established protocols and emerging research with critical perspectives on medical misinformation.• Serial cervical length monitoring after LEEP procedures lacks evidence for improving outcomes despite being common practice• SMFM's 2016 recommendation explicitly advises against routine cervical length screening for patients with history of cervical procedures• Retrospective studies on induction timing require careful interpretation due to inherent biases in methodology• Understanding the difference between intent-to-treat and per-protocol analysis is crucial when evaluating medical research• Pseudoscience and alternative medicine have gained mainstream acceptance over decades through celebrity endorsements and media platforms• Reusable surgical instruments like stainless steel uterine manipulators offer both economic and environmental advantages over disposable options• Plus, Learn the history of The Green Journal's distinctive colorBe sure to check out thinkingaboutobgyn.com for more information and follow us on Instagram. We'll be back in two weeks.00:00:35 Monitoring Cervical Length After LEEP00:10:30 Understanding Intent-to-Treat Analysis00:28:54 MAHA Movement and Medical Misinformation00:53:49 Carbon Footprint of Uterine Manipulators00:57:30 History of the Green JournalFollow us on Instagram @thinkingaboutobgyn.

Cervical cancer represents a success story in developed countries due to screening and vaccination, yet remains a significant global health problem with over 340,000 deaths annually worldwide. We explore the current state of cervical cancer prevention, screening, and treatment while discussing exciting advances that could eventually eliminate this disease.• Different levels of prevention for cervical cancer: primordial, primary, secondary, tertiary, and quaternary• HPV vaccination as the most effective primary prevention method, with Australia on track to make cervical cancer rare by 2035• Evolution from Pap smears to primary HPV testing, with potential future urine-based screening options• Less radical surgical approaches for early-stage disease, improving quality of life without compromising outcomes• Immunotherapy advances showing 6-12 month survival benefits in metastatic disease• Howard Kelly's pioneering work with radium in the early 1900s, establishing foundations for radiation therapy• Importance of addressing healthcare disparities, as rural Americans are 25% more likely to develop cervical cancer and 42% more likely to die from itVisit our website at thinkingaboutobgyn.com for more information and follow us on Instagram for updates.00:00:00 Introduction to Cervical Cancer00:08:10 Prevention Strategies Explained00:18:02 HPV Screening Evolution 00:26:51Treatment of Early-Stage Disease00:37:09Advances in Locally Advanced Disease00:50:31 Radium and Howard Kelly's History01:02:48 Final Thoughts on PreventionFollow us on Instagram @thinkingaboutobgyn.

Howard and Antonia explore the evidence behind pit breaks in labor, cannabis use in pregnancy, and IUD options for hormone replacement therapy.• Pit breaks in labor lack substantial evidence of benefit when used in active labor• Current research suggests stopping oxytocin during active labor may slightly increase cesarean rates rather than decrease them• Long pit breaks (up to 8 hours) in latent labor may be beneficial by allowing rest and promoting patience• Recent systematic review shows prenatal cannabis use increases risk of low birth weight by 75%, preterm birth by 50%, and perinatal mortality by 29%• Cannabis use during pregnancy (7.2% of pregnant women) now exceeds tobacco use• Retrospective studies on doula care show association with better outcomes, but can't establish causation due to inherent differences in patients who seek doulas• 52mg levonorgestrel IUDs (Mirena/Liletta) are suitable for endometrial protection during HRT, but evidence only supports use up to 5 years• Most systematic reviews combine heterogeneous studies and shouldn't be considered level 1 evidenceWe'd love to hear your questions! Send them to us through our Instagram or website thinkingaboutobgyn.com.00:04:52 Pit Breaks in Labor00:15:32 Examining Evidence on Oxytocin Discontinuation00:26:08 Prenatal Cannabis Use and Adverse Outcomes00:36:07 Doula Care Study Analysis00:57:22 Levonorgestrel IUD Use in HRTFollow us on Instagram @thinkingaboutobgyn.

Join Howard and Janeen Arbuckle for this discussion of pediatric and adolescent gynecology essentials. Pediatric and adolescent gynecology is a newer discipline bringing specialized care to young women with unique gynecologic needs, with a focus on counseling, education, and age-appropriate interventions. • Abnormal uterine bleeding in adolescents is rarely caused by structural problems (unlike in adults) and typically relates to immaturity of the hypothalamic-pituitary-ovarian axis• Hematologic workup should be considered for adolescents with heavy menstrual bleeding as this may be the first time their clotting system is challenged• Hormonal therapies are safe to use once menarche has occurred, with no impact on bone growth• Long-acting reversible contraceptives offer superior pregnancy prevention (1 in 10,000 for implants vs 8 in 100 for typical pill use) but require thoughtful counseling• Private interviews with adolescent patients create trust while preparing them for independent healthcare navigation• Tranexamic acid is effective for heavy menstrual bleeding in adolescents but pill size and frequency can limit compliance• Most ovarian cysts in adolescents represent normal physiologic function and rarely require intervention• Preservation of reproductive organs should be prioritized in adolescent surgery, including leaving ovaries after torsion when possible• Vaginal bleeding in pre-pubertal girls requires assessment for secondary sexual characteristics to distinguish precocious puberty from other causes00:00:00 Introduction to Pediatric Gynecology00:07:20 Abnormal Uterine Bleeding in Adolescents00:19:36 Contraception Choices for Young Patients00:29:40 Managing Difficult Patient-Parent Conversations00:38:04 Pelvic Pain and Endometriosis00:46:58 Adnexal Pathology and Ovarian Issues00:50:51 Congenital Anomalies and Vaginal BleedingFollow us on Instagram @thinkingaboutobgyn.

In this episode, Antonia and Howard explore the groundbreaking study on treating male partners for bacterial vaginosis, revealing significantly reduced recurrence rates and challenging our traditional understanding of BV pathophysiology.Plus: • Evidence doesn't support treating mild gestational hypertension with antihypertensives• Studies confirm acetaminophen in pregnancy doesn't cause ADHD or autism• New research questions the benefit of routine postpartum thromboprophylaxis• The history of heparin and coumadin00:00:34 Treating Mild Hypertension in Pregnancy00:06:14 Distinguishing Chronic vs. Gestational Hypertension00:15:46 Male Partner Treatment for Recurring BV00:27:09 Understanding Bacterial Vaginosis Pathophysiology00:35:42 Ineffective Treatments and Alternative Approaches00:53:04 Tylenol in Pregnancy: Debunking ADHD Claims00:58:02 Postpartum Thromboprophylaxis: Evidence Against OveruseFollow us on Instagram @thinkingaboutobgyn.

This episode features our favorite podcast ninja, Dr. Maddie White. She and Howard discuss how medical dramatizations misrepresent obstetric emergencies (yes, we are watching The Pitt). Then, we dissect evidence-based approaches to common triage scenarios including labor evaluation, rupture of membranes, and preterm labor assessment.• Television shows like "The Pitt" and "ER" portray shoulder dystocia and postpartum hemorrhage inaccurately, lacking proper urgency and technique• Hospital-based labor triage often costs approximately 10 times more than office-based evaluation, often without clinical benefit• Understanding pretest probability fundamentally changes how test results should be interpreted for suspected rupture of membranes• Most expensive tests like Amnisure (>$500) provide minimal additional value over traditional approaches when interpreted properly• Evidence doesn't support routine use of fetal fibronectin testing in preterm labor evaluation• We discuss universal cervical length screening for prevention of preterm labor in the midtrimester and later in pregnancy for evaluation of threatened preterm labor00:00:53 Critiquing Obstetric Emergencies in TV Shows00:10:13 Proper Management of Shoulder Dystocia00:14:52 Postpartum Hemorrhage Management Approaches00:19:59 Evaluating Term Labor Complaints00:25:35 Rupture of Membranes Testing Strategies00:34:12 Understanding Test Probability and Performance00:42:26 Cervical Length Screening Evidence00:51:23 Preterm Labor Triage Tools01:00:23 Concluding Thoughts on Evidence-Based PracticeFollow us on Instagram @thinkingaboutobgyn.

Antonia Roberts and Howard Herrell review several new articles: • Epifoam for postpartum pain lacks evidence of effectiveness compared to simple ice packs while costing nearly $100 per unit• AMH levels above 5.39 are associated with PCOS diagnosis, providing a specific threshold for clinical use• External aortic compression demonstrated as a life-saving technique during severe obstetric hemorrhage• Vaginal estrogen in breast cancer survivors shows no increased risk of cancer recurrence or mortality• Delayed cord clamping in preterm twins reduces mortality by 30% and significantly decreases transfusion needsThen they discuss new birth control options while questioning the value of expensive pharmaceutical products compared to established, less costly alternatives.• New birth control options like Balcoltra ($280/month), FemLyv ($215/month), and Nextstellis ($250/month) offer minimal innovation over generic alternatives costing $10-15/month• Marketing terms like "bioidentical" and "plant-based" are often misleading as all hormonal contraceptives are synthesized from plant precursors• Progestin-only pills like Slynd provide only marginal DVT risk reduction (5 vs 4 per 100,000 person-years) compared to low-dose combined pillsCheck our Instagram for more information and join us again in two weeks for our next episode.00:00:00 Introduction and Epifoam Discussion00:06:27 Financial Impact of Unnecessary Treatments00:11:09 AMH Levels for PCOS Diagnosis00:15:11 External Aortic Compression for Hemorrhage00:20:22 Vaginal Estrogen and Delayed Cord Clamping00:21:51 New Birth Control Products Overview00:31:05 Analyzing Dissolvable Birth Control Pills00:34:22 Slynd: Drosperinone-Only Pill Evaluation00:42:09 Nextstellis and "Bioidentical" Estrogen Claims00:56:37 History of Birth Control DevelopmentFollow us on Instagram @thinkingaboutobgyn.

We discuss the pressing issues surrounding operative vaginal deliveries, including trends in their usage and the disparities impacting delivery outcomes. Join us as we navigate these critical insights with expert guests Jamie Perry and Howard Herrell, revealing the complexities and nuances surrounding forceps and vacuum deliveries.• Examining the historical context of operative vaginal deliveries • Analyzing the decline in forceps and vacuum usage since the 1990s • Discussing the rise of cesarean deliveries as an alternative • Revealing racial disparities adjacent to delivery practices • Outlining effective techniques for both forceps and vacuum-assisted deliveries Learn more about this pressing topic and gain valuable insights by listening to our episode.00:00:00 ntroduction and Overview of the Episode00:01:18 The Decline in Operative Vaginal Deliveries00:05:24 Forceps00:24:21 Vacuums00:49:30 Advice For Trainees00:55:38 Four Tips for Forceps and VacuumsFollow us on Instagram @thinkingaboutobgyn.

This episode dives into the debate surrounding the efficacy and cost of barbed sutures in surgical practice, questioning whether their time-saving advantages are justified compared to traditional techniques, especially for uterine closure. Additionally, it explores the implications of non-invasive prenatal testing for cancer detection and recent maternal mortality statistics, while advocating for evidence-based practices in both surgical and obstetric care. • Analysis of barbed suture use and cost implications • Discussion of unexpected cancer detection via NIPS • Exploration of maternal mortality statistics and misconceptions • The relative value of baby (a discussion of the perverse economics of pediatric and obstetric care)• Summary of recent findings on aspirin dosages for preeclampsia • Examination of venous thromboembolism risks with hormonal contraceptives00:00:01 Barbed Suture in OBGYN Surgery00:09:13 Comparing Surgical Sutures00:17:11 NIPS Results and Maternal Cancer Detection00:24:04 Maternal Mortality Trends and Data Analysis00:38:50 Medical Reimbursements and Healthcare Priorities00:47:20 Risk Factors in Birth Control Thromboembolism00:54:37 Birth Control and Thromboembolism RiskFollow us on Instagram @thinkingaboutobgyn.

Join Howard with guest host Jacqueline Vidosh as we explore the challenges of maternal cardiac arrest. This episode emphasizes the urgent need for specialized training in obstetric life support. From discussing causes of maternal mortality to sharing practical tips for first responders, the insights presented aim to enhance awareness and preparedness in critical situations.• Discussing the alarming rise in maternal mortality rates• Identifying common causes of maternal cardiac arrest• The importance of OBLS training and education for healthcare providers • Emphasizing the need for left uterine displacement during resuscitation • Addressing healthcare disparities affecting Black women • Sharing unique physiological adaptations in pregnant patients • Strategies for improving outcomes in maternal cardiac arrest cases • Highlighting the value of simulation training for all healthcare personnel Every healthcare professional plays a role in improving maternal health outcomes. Listen in for tips and insights on how we can enhance readiness for maternal cardiac arrest situations.00:00:01 Obstetric Life Support00:03:34 Maternal Mortality and OBLS Training00:15:23 Maternal Health Disparities and Physiologic Changes00:27:53 Cesarean Delivery and Post-Delivery Care00:41:15 History and Implementation of CPRFollow us on Instagram @thinkingaboutobgyn.

In this episode, Howard and Antonia focuses on the evolving guidelines for HPV screening and the implications for women's health, highlighting its superior effectiveness over traditional Pap smear tests. Additionally, we explore the reliability of pregnancy apps for information and address a listener question about Group B Streptococcus screening and management. • Discusses the transition to HPV testing as primary cervical cancer screening • Reviews a recent study confirming HPV's effectiveness in preventing cervical cancer • Examines the reliability and misinformation in pregnancy apps • Answers listener questions regarding Group B Streptococcus management 00:00:01 Circumvallate Placenta00:13:51 Evaluating Pregnancy Apps for Accuracy00:26:56 Evaluating Risks of Pregnancy Apps00:36:51 Gestational Diabetes Treatment Options00:45:47 Manage GBS Risk FactorsFollow us on Instagram @thinkingaboutobgyn.

Discover how cesarean hysterectomy, once a procedure shrouded in fear, has evolved into a life-saving operation with contributions from pioneering figures like Eduardo Porro and Lawson Tate. In this episode, we are joined by gynecologic oncologist Stuart Winkler, who shares invaluable insights into both unplanned and planned cesarean hysterectomies. Explore the primary indications for these critical surgeries, from uncontrollable bleeding in unplanned emergencies to managing known conditions like placenta accreta in planned scenarios. You'll gain a deep understanding of the strategic decision-making required, especially in resource-limited environments, to ensure the best outcomes for patients.Navigate the complexities of performing cesarean hysterectomies under challenging circumstances, particularly when severe hemorrhage threatens patient safety. We delve into surgical tips and techniques, emphasizing the significance of early and careful bladder dissection, effective use of energy sealing devices, and confident decision-making. Our discussion highlights innovative strategies for uterine preservation in placenta accreta spectrum disorders, offering creative solutions when complete resection isn't feasible, and exploring new protocols that balance operative blood loss and patient fertility.Finally, take a journey through the historical evolution of cesarean hysterectomy with us, as we trace its transformation from a fearful, last-resort measure to a cornerstone of modern obstetric care. Learn about the pivotal technological advancements that have shaped current practices, such as preoperative arterial occlusion techniques, equipping today's surgeons with a wide array of tools to tackle even the most complex cases. This episode promises a comprehensive blend of historical insights and practical advice, making it an essential listen for both seasoned professionals and those new to the field.00:00:01 Cesarean Hysterectomy00:09:14 Surgical Tips for Cesarean Hysterectomy 00:17:42 Advanced Techniques in C-Hysterectomy00:23:56 Surgical Tips for Planned C-Hysterectomy00:31:36 Surgical Techniques for Hemorrhage Control00:41:38 Uterine Preservation in Spectrum Placenta00:53:37 Evolution of Cesarean HysterectomyFollow us on Instagram @thinkingaboutobgyn.

Challenge preconceived notions in obstetrics and gynecology with our latest episode, where we dismantle myths that have long influenced medical practices, even in the absence of scientific backing. From unraveling the misunderstood reaction between alcohol and metronidazole to examining the overlooked risks of clindamycin cream, we'll look at how these misconceptions take root in medical culture. We continue with a critical analysis of intrapartum GBS prophylaxis, correcting widespread misunderstandings around its purpose and timing during labor and how it affects labor management.We address the rise of dubious hormone tests, like the DUTCH Test, marketed to consumers, painting a cautionary picture of how social media amplifies these unvalidated products. We highlight the importance of consulting healthcare professionals while discussing the potential paradigm shift that self-collected HPV testing could bring to cervical screening, as recommended in the coming cervical cancer screening guiudelines. This new approach might revolutionize screening rates and quality of care, especially for underserved populations, all while realigning healthcare providers' focus on more pressing medical needs.Prepare for an engaging conclusion as we scrutinize the comparative effectiveness of postpartum hemorrhage devices Jada and Bakri, emphasizing the ethical implications of cost versus efficacy. We'll take you on a historical journey through the concept of "quickening" in pregnancy, reflecting on its cultural significance and evolution with modern science. Plus, changes for next season!00:00:02 Metronidazole and Alcohol00:13:03 Intrapartum GBS Prophylaxis Guidelines Clarified00:24:54 Hormone Testing and Cervical Screening 00:31:07HPV Self-Collect Screening Implications00:42:54 Comparative Efficacy of Postpartum Hemorrhage Devices00:51:29 Historical Perspectives on Fetal DevelopmentFollow us on Instagram @thinkingaboutobgyn.

In this episode, we give four simple tips for performing a Pap smear. Then we dive into the complicated problem of obstetric units closing across the United States and actions we need to take to stop this dangerous trend that threatens the safety of pregnant women and newborns. Also, we highlight the important of hospital based obstetric programs and the history of why births moved into the hospitals in the beginning of the 20th Century and the 99% decline in maternal and neonatal mortality that followed. 00:00:02 Cervical Cancer Screening Tips00:14:13 Hospital Closures Affect Obstetric Care00:37:27 Rural Obstetric Units Closing Challenges00:44:53 Hospital vs. Home Birth Safety00:49:40 Healthcare Disparities for Women and Children00:55:08 Evolving Birth Settings in America01:02:28 Email Advocacy for Healthcare ReformFollow us on Instagram @thinkingaboutobgyn.

Do patients in labor need continuous bladder drainage? We will review the literature comparing intermittent to continuous drainage. Next, we venture into the art and science of manual rotation for persistent posterior fetal presentations, a skillful maneuver that might just hold the key to lowering cesarean rates. Drawing from comprehensive reviews and trials, including the TURN-OUT trial and studies from UCSF, we debate the efficacy and applicability of manual rotation in various clinical settings. From ultrasound-guided techniques to hands-on learning, gain a nuanced understanding of how this practice might enhance delivery outcomes and reduce interventions. Finally, we learn about Cesarean Scar Disorder, a relatively new diagnosis with important clinical ramifications. 00:00:10 Urinary Catheterization in Labor Management00:16:10 Manual Rotation of the OP Fetus00:49:32 Effectiveness of Labor Positioning Techniques00:58:03 Cesarean Scar DisorderFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss four tips for effective birth control counseling. By dissecting communication techniques, we highlight how striking a balance between relational and task-oriented approaches can maximize patient interactions and ensure comprehensive, evidence-based care regarding birth control choices.Then we delve into several studies from the recent ABOG MOC cycle that we found interesting or curious and point out several informative nuggets.Finally, we discuss the book "Feminine Forever" and its impact on estrogen replacement therapy perceptions. 00:00:02 Communication Strategies for Birth Control Counseling00:11:56 Effective Communication of Birth Control Risks00:21:08 PAS After Myomectomy00:23:03 Risk-Reducing Surgery Adherence Discussion00:30:33 Issues With Modern Labor Curves00:38:49 Stopping ASA Early00:42:17 Prophylactic Slings00:46:01 Clinical Updates on UTIs00:51:34 Mental Health Guidelines and Other Articles00:55:51 Feminine ForeverFollow us on Instagram @thinkingaboutobgyn.

Can IV fentanyl use during labor actually be safe for mothers and newborns beyond six centimeters of dilation? Join us as we unpack a pivotal 1989 study and question the stereotypes surrounding fentanyl use in labor.Our second segment tackles sensational claims about IUDs and breast cancer, as we dissect a Danish study recently published in JAMA. Listen as we unpack the methodological nuances and confounders that mainstream publications have overlooked, and explore the media's role in shaping public perception with incomplete or skewed interpretations of data.This episode closes with an in-depth look at the biases that pervade pharmaceutical research, particularly when funding sources have a vested interest in outcomes. By examining the "sponsorship effect" and its implications on research validity, we highlight the need for rigorous, unbiased scientific inquiry. We examine the evidence for the new Pretrm Test for preterm labor risk. Learn about the challenges of implementing biomarker testing for predicting preterm births and why high-quality evidence must remain the cornerstone of clinical practice. As we celebrate our 100th episode, we discuss the need for truth and transparency in scientific research—creating a future where clinical practices are driven by reliable, evidence-based insights.00:00:02 Navigating IV Fentanyl Use in Labor00:07:56 Debunking Misconceptions About IUDs and Breast Cancer00:22:17 Evaluating Biomarker Testing for Preterm Birth: The PreTRM test00:38:50 Conflicts of Interest in Medical Research00:45:15 Biased Influence in Medical ResearchFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss four tips for finding evidence based answers quickly. Then we discuss some new literature about pap smears and new guidelines regarding iron supplementation in pregnancy. We also discuss the history of corticosteroids for fetal maturity and the hype cycle in medicine.00:00:02 Finding Evidence-Based Clinical Answers Quickly00:13:36 Understanding Evidence-Based Clinical Practice00:23:30 Cervical Cancer Screening During Pandemic00:33:51 Optimal Timing for Cervical Cancer Prevention00:40:12 Iron Supplementation in Pregnancy00:47:13 Corticosteroids and Hype in MedicineFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss the evidence behind one layer and two layer Cesarean closures with an emphasis on inclusion of the endometrium and the risk of cesarean scar ectopics and placenta accreta spectrum disorders. Plus, we define minimally invasive surgery and trace the origin of the term and it's introduce a new concept: less invasive vs minimally invasive surgery. 00:00:02 Hysterotomy Closure Techniques in Cesarean Deliveries00:14:46 Debunking Claims About Cesarean Techniques00:27:20 Uterine Closure Techniques in Cesarean Deliveries00:36:44 Defining Minimally Invasive Surgery00:48:18 Advanced Techniques in Minimally Invasive SurgeryFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss four tips for placing and using catheters for induction of labor. Then we revisit the issue of small for gestational age versus fetal growth restriction. We also discuss the most common mistake made in calculating due dates and how this can have a negative impact on pregnancies. Finally, we discuss the history of postpartum depression and the literature and stories of Kate Chopin and Sylvia Plath. 00:00:35 Four Tips for Cervical Catheter Placement00:23:00 SGA vs FGR00:28:55 Correcting Due Dates Prevents Mistakes00:46:10 History of Postpartum Depression, Chopin and PlathFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss the frequency of Pap smears for twin pregnancies as well as the need for using twin-based growth data for the diagnosis of fetal growth restriction in twins. We will poke the fire of controversy of the use of the terms "fetal growth restriction" and "small for gestational age" and discover how the terms might harm pregnancies. Next, we discuss the new AAP guidelines for diagnosis of tongue ties. Finally, we answer a listener question about pushy doctors, paying for unnecessary tests, and the disconnect many gynecologists have with guideline and evidence based care. 00:00:02 Ultrasound Use in Twin Pregnancies00:14:06 Twin Growth and Fetal Growth Restriction 00:20:00 Fetal Growth Assessment in Twin Pregnancies00:29:10 Overdiagnosis of Tongue Tie in Infants00:38:05Breastfeeding and Tongue Tie Recommendations00:45:43 Controversy Surrounding Pelvic Exams00:58:21 Unnecessary Physical Exams and IUD PreferencesFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss prevention of thromboembolism during pregnancy and the postpartum period and the evidence for which patients should receive anticoagulation. Plus, the history of heparin and four tips for preventing embolism. 00:00:02 Four Tips for Preventing Thromboembolism in Obstetrics00:08:39 Anticoagulation Recommendations in Pregnancy00:22:29 Assessing Anticoagulation Recommendations in Pregnancy00:35:22 Evaluating Anticoagulation Protocols in Pregnancy00:42:22 Debating Risks of Obstetric Anticoagulation00:59:28 History of HeparinFollow us on Instagram @thinkingaboutobgyn.

In this episode, we challenge the reliability of traditional tests like Homan's sign and cervical motion tenderness. Learn how understanding and applying likelihood ratios can vastly improve diagnostic accuracy, and why combining multiple findings is more reliable than putting faith in isolated tests.Then we discuss a new JAMA study linking advanced endometriosis with a heightened risk of ovarian cancer. The study brings to light the complexities and gaps in our knowledge, underscoring the importance of personalized patient discussions regarding risks and treatment options. Next, we discuss a new study about how surgical residents are treated during residency. From inadequate parental leave to cultural pressures, we highlight the urgent need for systematic changes to foster a supportive and equitable environment. Then expose the deceptive practices in the umbilical cord blood banking industry, revealing the ethical issues and questioning the touted benefits. Finally, we answer listener questions about use of sterile gloves for cervical exams and trials of labor after two cesareans. 00:00:02 Obsolete Physical Exam Maneuvers in Gynecology 00:14:25 Endometriosis and Ovarian Cancer Risk00:20:47 Residency Challenges for Parents and Discrimination00:33:10 Deceptive Practices in Cord Blood Banking00:49:19 Debate on Mammography Guidelines00:54:17 Listener Questions: Sterile Gloves and VBA2CFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss four tips for Cesarean under local. Then we discuss some new literature including full versus empty bladder during gyn procedures and endometrial ablation vs IUD for abnormal uterine bleeding. We also discuss the inertia of old ideas in obstetric practice. Finally, we discuss the history of the diagnosis of preeclampsia and eclampsia. 00:00:02 Cesarean Delivery Under Local Anesthesia00:07:04 Emergency Cesarean Delivery Procedure00:19:47 Bladder Status in Gynecological Procedures00:29:01 Endometrial Ablation vs IUD for Treatment00:38:43 Inertia in Obstetrics Practice Trends00:47:45 Historical Evolution of Eclampsia DiagnosisFollow us on Instagram @thinkingaboutobgyn.

In the season 8 premiere, we discuss over-utilization of serial quantitative HCGs. Then we discuss several famous or influential studies in obstetrics, including the WOMAN trial, the CLASP trial, the ARRIVE trial, MagPIE, and several more. Finally, we discuss the history of how magnesium sulfate came to be used in obstetrics. 00:00:02 Overuse of HCG00:13:17 Aspirin for Preeclampsia Prevention Debate00:18:51 Debate on the ARRIVE Trial00:29:10 MagPIE00:39:05 Fetal Fibronectin Trials00:44:53 Induction at 41 Weeks Discussion00:55:16 History of Magnesium Use in ObstetricsFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss four tips for uterine inversion. Then, we discuss mistreatment and abuse of trainees in OB/GYN plus physician suicide. Finally, we answer a question about closure of peritoneum. 00:00:02 Managing Uterine Inversion in Obstetrics00:13:39 Combatting Harassment in Medical Training 00:25:41 Addressing Mistreatment in Medical Training 00:31:13 Workplace Mobbing and Bystander Dynamics 00:37:29 Identifying and Addressing Workplace Abuse 00:59:30 Listener QuestionFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss routine bacterial vaginosis screening in patients with preterm labor symptoms. Then, we discuss some dietary and other less-discussed findings from the Women's Health Initiative. We also discuss a new review article about first trimester anatomic ultrasounds. Finally, we answer a listener question about implementing postpartum sterilization routinely into unsupportive hospitals. 00:00:02 Testing for BV in Preterm Labor00:12:28 Clinical Diagnosis of Bacterial Vaginosis00:21:14 First Trimester Ultrasound in Women's Health00:34:12 First Trimester Ultrasound Anomalies and Costs00:38:29 The Cost-Effectiveness of Early Ultrasounds00:46:32 Improving Postpartum Sterilization Access00:55:32 Strategies for Postpartum Sterilization ProceduresFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss four tips for IUD insertion. Then we discuss the qualities of good teachers and the important of teaching students and residents, with some practical advice thrown in as well. Finally, we discuss the history of blood transfusion. 00:00:02 IUD Insertion Techniques and Anxiety Management00:23:04 Qualities of a Great Teacher00:35:16 The Benefits of Teaching in Medicine00:45:42 Teaching Strategies for Clinical Preceptors00:52:33 History of Blood Transfusion & ObstetricsFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss the risks and counseling related to higher numbers of Cesareans. Then, we finish our discussion about vaginal hysterectomy with tips and tricks for some common problems. Finally, we answer a listener question about external cephalic version. 00:00:02 Considerations for Multiple Cesarean Deliveries00:08:13 Risks and Outcomes of Cesarean Hysterectomies00:16:09 Uterine Dehiscence and Vaginal Hysterectomy00:24:01 Tips for Vaginal Hysterectomy Assistants00:35:24 Mastering the Anterior Colpotomy Technique00:44:01 Vaginal Hysterectomy Tips and Techniques00:55:36 Teaching Vaginal Hysterectomy Techniques00:57:55 Listener Question about ECVFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss four tips for managing the deeply impacted fetal head at the time of Cesarean. Then we discuss the optimal route of hysterectomy (hint: its a vaginal hysterectomy). Finally, we discuss the obstetric history of the Taj Mahal. 00:00:02 Four Tips For Deeply Impacted Head at Cesarean00:13:53 Advantages of Vaginal Hysterectomy00:25:16 Optimizing Vaginal Hysterectomy Techniques00:31:53 Advancing Skills in Minimally Invasive Surgery00:40:24 Advancements in Vaginal Hysterectomy Technique00:49:20 Debating the Merits of v-Notes00:58:06 Taj Mahal and Maternal MortalityFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss the latest recommendations for treatments for osteopenia and osteoporosis, including vitamin D and calcium, as well as bisphophonates and other medications. Then we discuss new literature about best methods for induction of labor and risks factors for uterine rupture during a trial of labor after Cesarean. We also discuss a new trial about late preterm antenatal steroids.Also we talk about a new article about mammalian menopause the evolutionary rolls of menopause and concealed ovulation (fun people, we know!) Finally, we answer a listener question about bleeding during surgery. 00:00:02 Treatment of Osteopenia and Osteoporosis00:14:40 Vaginal Birth After Cesarean Recommendations00:24:05 Effectiveness of Late Preterm Steroids00:35:49 Menopause and Evolution in Mammals00:41:05 Concealed Estrus and Weight Gain Recommendations00:47:56 Managing Surgical Hemostasis and BleedingFollow us on Instagram @thinkingaboutobgyn.

In this episode, Dr. Stuart Winkler returns to discuss new evidence about the risks and benefits of radical hysterectomy for cervical cancers. Also, for fun, we torture a Gyn-Onc with a four tips for managing cord prolapse.  Also, we discuss a new commentary on activity restriction after gynecologic surgery. 00:00:02 Management of Cord Prolapse in Labor00:11:01 History and Evolution of Radical Surgery00:25:03 Recent Trials on Cervical Cancer Surgery00:48:33 Activity Restrictions in Surgical PracticeFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss which laparoscopic ports need to be closed and how. Plus, we discuss more evidence that the current narrative about maternal mortality in the US is false. Finally, we answer listener questions about oxytocin protocols and the history and utility of the Bishop's Score. 00:00:02 Closing Laparoscopic Ports 00:13:32 The Maternal Mortality Rate Debate 00:21:04 Maternal Mortality Misconceptions and Progress00:30:30 Maternal Mortality Misconceptions and Data Accuracy00:39:27 The Bishop's Score 00:45:41 Debating Oxytocin and Labor PoliciesFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss four tips for breech vaginal delivery.  Then, we respond to the Alabama Supreme Court's decisions about embryos and the impact on IVF and reproductive rights. Finally, we discuss the best methods for initial laparoscopic entry and discuss the history of laparoscopy. 00:00:02 Four Tips for Vaginal Breech Deliveries00:13:17 Alabama Supreme Court and IVF00:29:15 Initial Laparoscopic EntryFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss the use of supplemental oxygen for fetal decelerations. Then we get into part 2 of our discussion of interpreting clinical studies and when to adopt new interventions into practice, including a discussion of intranasal metoclopramide, elagolix, and a new study about an app based doula service. Finally, we answer user questions about surprise billing at the time of annual exams and the pros and cons of egg freezing. 00:00:02 Oxygen Supplementation in Labor00:11:00 Interpreting studies part 2: intranasal metoclopramide00:22:07 Evaluating Efficacy of Elagolix for Endometriosis00:38:23 Doulas and Birth Outcomes00:44:32 Listener Question: Surprise Billing00:51:30 Listener Question: Egg PreservationFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss four tips for external cephalic version. Then we dive into the basics of interpreting scientific studies. Finally, we discuss the pregnancy history of Jackie Kennedy. 00:00:20 Tips for External Cephalic Version00:17:10 Evaluating Clinical Studies00:53:13 Jackie Kennedy's Impact on Cesarean DeliveriesFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss performing Cesarean for fetal weights at lower thresholds than currently recommended. Then we discuss new literature regarding utility of pelvic exams or screening asymptomatic women and early rupture of membranes after cervical ripening with a Foley bulb. Then we discuss an editorial discussing selecting the best test and hysteroscopy for miscarriage after embryo transfer. Plus, a new RCT that examines stopping oxytocin once a patient is in active labor. Finally, we answer listener questions about harms of yearly pap smears and whether we plan to use Zuranolone for treatment of postpartum depression. Buckle up!00:01:00 Cesarean for Fetal Weight > 4000 g00:13:20 Pelvic Exams in Asymptomatic Women00:30:10 Early Amniotomy After Foley Bulbs 00:33:43 The Best Test: Hysteroscopy for Miscarriage00:40:59 Stopping Oxytocin in Active Labor00:45:00 Listener Question: Harms Of Yearly Paps00:55:26 Listener Question: ZuranoloneFollow us on Instagram @thinkingaboutobgyn.

In the first episode of our new season, we introduce a new segment with Four Tips for managing fetal heart tracings. Then we discuss the new mammography guidelines. And finally we discuss a case of a viable pregnancy in a woman who had had a hysterectomy. 00:20:45 Mammography Guidelines00:30:12 Debating the Effectiveness of Mammography Screening00:41:01 Breast Cancer Screening and Overdiagnosis00:55:50 Pregnancy After HysterectomyFollow us on Instagram @thinkingaboutobgyn.

In this episode, we discuss five more myths about hormone replacement therapy. Also, we discuss the utility of cervical exams at later pregnancy visits and the history of synthetic hormones. 00:00:02 Intro and Routine Cervical Exams00:07:51 Myth #6: Lowest dose, shortest duration00:17:27 Myth #7: Women without a uterus need progesterone 00:22:44Myth #8: Transdermal estrogen is safer than oral00:36:25 Myth #9: All menopausal women should also be on Testosterone replacement00:39:50 Myth #10: Ineffective alternative treatments00:53:04 History of hormone products

In this episode we debunk the first of five myths about menopausal hormone replacement therapy. 00:00:02 Hormone Replacement Therapy For Smokers, HTN00:11:42 Misinformation from Women's Health Initiative00:17:18 Myth 1: Estrogen and Breast Cancer00:28:06 Myth 2: HRT and BRCA Patients00:33:17 Myth 3: Estrogen and Cardiovascular Disease00:39:14 Myth 4: Bioidentical Hormones00:51:00 Myth 5: Checking Hormone Levels

In this episode, we discuss several new articles related to treatment of vaginal atrophy or genitourinary syndrome of menopause, including literature that clarifies the role of vaginal estrogen cream. Plus, we discuss the role of washings at the time of management of adnexal masses. We also discuss new literature about the true impact of oxytocin on postpartum hemorrhage risk and examine a paper that claim that female gynecologists receive lower patient satisfaction scores than males. Finally, we discuss the true rate of pregnancy loss.  00:00:02 Peritoneal Washings in OBGYN Surgery00:21:16 Oxytocin and Postpartum Hemorrhage Connection00:28:23 Comparing Therapies for Menopausal Symptoms00:42:54 Female Gynecologists and Patient Satisfaction00:52:11 The True Rate of Pregnancy Loss

In this episode, we review the literature regarding the use of magnesium sulfate for neuroprotection to prevent CP in preterm infants. 00:00:02 Magnesium Sulfate for Neuroprotection00:11:00 The Controversy Surrounding Magnesium Sulfate00:36:37 Research Study Mistakes and Bias00:46:33 Magnesium Sulfate's Effects on Preterm Birth 00:52:24 Magnesium for Fetal Neuroprotection Reevaluated

In this episode, we discuss neonatal circumcision and the pros, cons, and ethics. Prepare for controversy. We also discuss the utility of labs for fetal growth restriction. 00:00:02 Circumcision Controversy00:05:00 Labs for Fetal Growth Restriction00:15:31 Global Perspectives on Male Circumcision00:26:17 Significance of Male Circumcision in History00:33:52 The Arguments for and Against Circumcision00:53:44 Ethical Considerations of Circumcision

In this episode, we speculate about the near future of advancement of obstetrics, including new vaccines, new uses for cell-free DNA screening, advancement in diabetes monitoring, the use of artificial intelligence and remote monitoring in obstetrics, and artificial womb technology. Also, do you need to stick the GBS swab in you know where? 00:00:02 GBS Swab Technique00:10:09 Emerging Innovations in Obstetrics00:18:35 Advancements in Vaccines and Prenatal Care00:27:49 Diabetes Management and Assisted Birth Advances00:39:06 AI, Prenatal Care and Fetal Monitoring Advances00:53:20 Advancements in Artificial Womb Technology

In this episode, we discuss the utility of repeat antibody testing at 28 weeks. Plus, new evidence about early screening for GDM, the concept of tension in the pelvic floor, the evidence about vaginal prep at the time of unplanned Cesarean, new literature about interventions for preterm birth, and the safety of Mayo (or raw eggs) during pregnancy.00:00:02 Repeating Type and Screen for RH-Negative Pregnant Women00:13:54 Evaluating Early Screening for Gestational Diabetes00:19:24 Discussing Outcomes of Gestational Diabetes Study00:27:17 Pelvic Therapy and Vaginal Cleansing00:37:30 The Controversy Surrounding Preterm Birth Interventions00:50:58 UK and US Egg Safety Standards

In this episode we welcome back Stuart Winkler to discuss over-consulting in OB/GYN and how to improve surgical eduction in our training programs and how to balance generalists vs subspecialists. Plus, colace!00:00:02 Misuse of Docusate Sodium00:09:24 Appropriate Specialty Referrals in Gynecology00:20:51 Considerations for EIN Management and Referrals00:33:57 Endometrial Ablation in Gynecologic Surgery00:41:53 Practice, Mentorship, Surgical Coaching Importance00:51:04 Speed and Surgical Competence00:57:59 Teaching and Expectations in OBGYN

In this episode we discuss the evolution and evidence behind vaginal delivery techniques. Plus, we discuss the importance of the golden hour after birth for the mother and baby. 00:00:02 Golden Hour Care After Birth00:09:23 Traditional Practices in Vaginal Deliveries00:20:54 Optimal Practices for Labor Management00:26:10 Monitoring and Positions in Labor00:30:52 Labor Positions and Pushing Techniques00:36:30 Episiotomy and Preventing Perineal Tears00:49:54 Third Stage and Cord Clamping Guidelines

In this episode, we discuss guidelines about bulb suctioning at the time of delivery. Then we discuss the nearly 100 year old schedule of prenatal visits and how these can be modernized. Finally, we discuss the next Eat, Sleep, Console approach for neonatal abstinence. 0:02Neonatal Suctioning11:33Reforming Prenatal Visits and Outdated Recommendations21:41Streamlining Prenatal Visits and Remote Monitoring28:47The Controversy Surrounding Home Dopplers33:36Efficiency and Effectiveness of Prenatal Visits40:48Prenatal Care and Biomarkers for Preeclampsia51:27Comparing Methods of Diagnosing NAS

In this episode, we discuss screening for BV to prevent preterm birth. Then new data about the safety of obstetric care in rural vs urban hospitals of different sizes. Plus, new evidence that prophylactic salpingectomy is working and new data about vaginal cuff dehiscence and the analogy between clinical studies and lab tests. 0:02Treating Bacterial Vaginosis in Pregnancy10:12Morbidity Rates in Rural and Urban Hospitals20:43Hospital Size and Patient Care Impact32:56Maternity Deserts37:04Salpingectomy for Ovarian Cancer Prevention44:10Analogy of Clinical Trials49:53Vaginal Cuff Dehiscence

In this episode, we discuss current evidence about post-surgical activity restrictions. Plus, we explore probiotics for GBS prevention, vaginal seeding, barbed sutures, disposable staples, and how to be faster during surgery.